MANAGING THE DEMANDMANAGING THE DEMAND

Dr Gerry BeattieDr Gerry Beattie

1919thth May 2010 May 2010

Demand management - Demand management - definitiondefinition

• Actions taken by primary care/trusts Actions taken by primary care/trusts and/ or GP practices to and/ or GP practices to moderatemoderate the the demand for health care servicesdemand for health care services

• Hospital demand management refers to Hospital demand management refers to actions taken to actions taken to moderatemoderate the rate of the rate of referrals of patients to hospitals referrals of patients to hospitals

NHS EvidenceNHS Evidence

DemandDemand

• Demand is not a given – it can be Demand is not a given – it can be influencedinfluenced

• Demand is constantly changingDemand is constantly changing

• As waiting times come down demand As waiting times come down demand may risemay rise

• In some main specialities demand is In some main specialities demand is risingrising

eg. ENT, neurosurgery, urologyeg. ENT, neurosurgery, urology

To manage demand -To manage demand -

• The interface between primary and The interface between primary and secondary care needs to be secondary care needs to be managedmanaged

• There is a need to assume a There is a need to assume a corporatecorporate ownershipownership of patient of patient pathways through primary and pathways through primary and secondary caresecondary care

DemandDemand

It’s all very well saving 10 pence in It’s all very well saving 10 pence in the pound, but perhaps what’s more the pound, but perhaps what’s more important is who spends the 90 important is who spends the 90 pencepence

Kings FundKings Fund

Management and demand at Management and demand at the interface between the interface between primary and secondary care.primary and secondary care.

Angela Coulter, Director of Policy and Angela Coulter, Director of Policy and Review, King’s FundReview, King’s FundBritish Medical Journal (1998) Vol 316, British Medical Journal (1998) Vol 316, 1974 - 19761974 - 1976

Why do GPs refer ?Why do GPs refer ?

• DiagnosisDiagnosis

• InvestigationInvestigation

• Advice on treatmentAdvice on treatment

• 22ndnd opinion opinion

• Reassurance for the patientReassurance for the patient

Continued ;Continued ;

• Sharing the load or risk of treating a Sharing the load or risk of treating a difficult or demanding patientdifficult or demanding patient

• Deterioration in the GP/patient Deterioration in the GP/patient relationship leading to a desire to relationship leading to a desire to involve someone else in the involve someone else in the management of the problemmanagement of the problem

• Fear of litigationFear of litigation• Direct request from patient or relativeDirect request from patient or relative

‘‘Collating information and feedback Collating information and feedback are important first steps in the are important first steps in the understanding of patterns of demand understanding of patterns of demand ‘‘

CoulterCoulter

Appropriate referralsAppropriate referrals

• NecessaryNecessary

• TimelyTimely

• Cost effectiveCost effective

• EffectiveEffective

What’s referred most -What’s referred most -

• Joint painJoint pain

• Hearing problemsHearing problems

• Abdominal painAbdominal pain

• Back painBack pain

• Breast lumpsBreast lumps

• Varicose veinsVaricose veins

• Visual problemsVisual problems

• MenorrhagiaMenorrhagia

ContinuedContinued

• Sterilisation / vasectomySterilisation / vasectomy

• Skin conditionsSkin conditions

• DepressionDepression

• Termination of pregnancyTermination of pregnancy

• TonsilsTonsils

• Otitis mediaOtitis media

• CataractsCataracts

Managing DemandManaging Demand

1. Knowing demand and flexing 1. Knowing demand and flexing capacitycapacity

2. Advice only referrals2. Advice only referrals

3. Ref help3. Ref help

4. Speciality GPs4. Speciality GPs

5. Direct access5. Direct access

1. Knowing demand and 1. Knowing demand and flexing capacity flexing capacity

• Gynaecology – unclear what the Gynaecology – unclear what the demand was in terms of numbers and demand was in terms of numbers and case mixcase mix

• Waiting time for GOPD was 16 weeksWaiting time for GOPD was 16 weeks

• 6 entry points into the system all with 6 entry points into the system all with separate booking systems – NRIE, separate booking systems – NRIE, WGH, SJH, LCTC, Roodlands, LibertonWGH, SJH, LCTC, Roodlands, Liberton

• Inequity of access and double slotting Inequity of access and double slotting

Centralised BookingCentralised Booking

• Referrals redirected on SCI Gateway to Referrals redirected on SCI Gateway to one central office in NRIE.one central office in NRIE.

• Patients seen by most appropriate person Patients seen by most appropriate person at the most appropriate site.at the most appropriate site.

• Ability to respond to pressures and better Ability to respond to pressures and better utilise specialist clinics with more effective utilise specialist clinics with more effective use of capacity.use of capacity.

• Waiting time for GOPD approximately 6 Waiting time for GOPD approximately 6 weeks across Lothian without additional weeks across Lothian without additional capacity.capacity.

• Prospective capacity modelling toolProspective capacity modelling tool

Audit of referralsAudit of referralsGynae Triage Audit - Oct 09

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

1 - MenstrualProblems

2 - Postmenopausal

bleeding

3 - Prolapse 4 - Urinaryincontinence

5 - Pelvic pain 6 - Pelvic mass- ovarian /fibroids

7 - Vulval /Vaginal lesion

8 - Gynae skins 9 -Contraception /

sterilisation /IUS

10 - IMB / PCB/Polyp/

Suspiciouscervix

11 - Advice only 12 - Otherincludingreferral

elsewhere (RepEndo / Infertility

/ Colp)

Pathway

1 - Appropriate and complete 2 - Appropriate and incomplete

3 - Discussion and / or more information may have prevented referral 4 - Inappropriate / dealt with in primary care

DNA’sDNA’s

• Sterilisation requestsSterilisation requests• MenorrhagiaMenorrhagia• Pelvic painPelvic pain

• But approximately 70% of But approximately 70% of DNAs are return patientsDNAs are return patients

DNA RateDNA RateGynae DNA Rates Oct 08 to Dec 09

0.00%

2.00%

4.00%

6.00%

8.00%

10.00%

12.00%

14.00%

16.00%

18.00%

20.00%

22.00%

Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

Month

DN

A %

New Patient Return Patient Grand Total

2. Advice only referrals2. Advice only referrals

• Examples in various specialities that this Examples in various specialities that this works well eg dermatologyworks well eg dermatology

• SCI gateway ‘advice only’ referrals being SCI gateway ‘advice only’ referrals being developed and piloted in gynaecologydeveloped and piloted in gynaecology

• Ultimately linked to TRAKUltimately linked to TRAK• Demand needs to be monitored closelyDemand needs to be monitored closely• Manpower needs to be in place in Manpower needs to be in place in

secondary care to deal with such secondary care to deal with such referrals referrals

3. Ref help3. Ref help

• On line referral supportOn line referral support

• Perceived as ‘user unfriendly’ at Perceived as ‘user unfriendly’ at presentpresent

• Services need to take ownershipServices need to take ownership

• Use as a shop window with up-to-Use as a shop window with up-to-date referral help and advicedate referral help and advice

4. Speciality GPs4. Speciality GPs

• Identify GPs with speciality interest Identify GPs with speciality interest to work with secondary careto work with secondary care

• Protocol and pathway developmentProtocol and pathway development• Focus for information dissemination Focus for information dissemination

and feedback in both directionsand feedback in both directions• Develop educational initiativesDevelop educational initiatives• Consolidate links between primary Consolidate links between primary

and secondary careand secondary care

5. Primary Care Access5. Primary Care Access

Removing access restrictions and Removing access restrictions and jointly redesigning jointly redesigning primary/secondary care interface primary/secondary care interface processes can improve the whole processes can improve the whole patient journeypatient journey

Primary Care AccessPrimary Care Access

• Expand the range of diagnostic tests Expand the range of diagnostic tests available in primary careavailable in primary care

• Direct access bookable slots in Direct access bookable slots in secondary caresecondary care

• Reduce referrals to secondary care Reduce referrals to secondary care and enhance local careand enhance local care

Primary Care AccessPrimary Care Access

• EchocardiographyEchocardiography

• Ambulatory BP recordingAmbulatory BP recording

• 24 hour tapes24 hour tapes

• Full pulmonary function testingFull pulmonary function testing

• CT/MRIs of knees, chest, neck, CT/MRIs of knees, chest, neck, abdomenabdomen

MRI lumbar spine – the Tayside MRI lumbar spine – the Tayside experience (April – Sept 2009)experience (April – Sept 2009)

• GP-OP-MRI-OP vs Direct access GP-MRI 34%GP-OP-MRI-OP vs Direct access GP-MRI 34% GP-MRI-OP 66%GP-MRI-OP 66%

• GP to OP to MRI to OP - 24 weeks GP to OP to MRI to OP - 24 weeks GP to MRI to OP - 12 weeksGP to MRI to OP - 12 weeks

• Out patient attendances dropped by 66% Out patient attendances dropped by 66%

Questions ?Questions ?